In order to successfully clinically manage pain, it is essential to begin with an understanding of the underlying mechanisms responsible for its generation. A skillful approach based upon better knowledge concerning the anatomical structures, pathways, and events that result in pain is more likely to lead to effective clinical management of pain. The discussion will include an overview of medication classes typically considered for pain and the pathways they affect.

The gabapentinoids are a popular class of medications among prescribers for use in chronic pain and various other neurological conditions. In fact, prescription rates for both gabapentin and pregabalin have increased in the United States and other countries in recent years. However, these medications have a street value to a newer niche of users, including patients taking them at megadoses to enhance the effects of other psychotropic drugs, and other patients taking them to manage or mitigate opioid withdrawal symptoms and possibly even opioid cravings. While pregabalin is already classified as a controlled substance, gabapentin does not yet carry this classification. In response to rising abuse, various states and regulatory bodies are considering changes to enhance patient safety and protect the provider's license. Learn what changes you should make to your practice, if any, in light of the growing abuse of gabapentinoids and how to identify patients potentially abusing them.

Despite high prevalence and seemingly continuous attention, the clinical challenges associated with assessing, treating, and managing patients with chronic pain continue to persist. Many different forces are at play and responsible for this frequently frustrating situation and, as is often the case, the person with the most at risk is the patient with chronic pain. There is no deficit of opinions for possible solutions to this problem. In fact, the number of potential solutions seems to increase each year, all with the intent of helping pain care be more safe and effective, and most trying to stem the negative consequences of abuse, misuse, and diversion of prescription pain medications. Clinicians have had to juggle these good intentions along with the fear of regulatory scrutiny. This course will present and detail the variety of current regulatory forces that need to be considered in clinical practice; how they can potentially impact clinical decisions regarding chronic pain; and how they can be negotiated. A number of regulatory agencies are now "sitting at the pain management table" for the foreseeable future and it is critical to navigate the waters without sacrificing that most important stakeholder: the patient.

Diagnostic testing is an integral component for the differential diagnosis. In routine clinical practice there has been a tendency for clinical examinations to become more cursory, largely influenced by increasing demands of time and patient expectations of technological advances. The end result may arguably lead to an overreliance on technology for basic clinical diagnosis. The purpose of this session is 2-fold. It is meant to provide a review and, for some, an introduction to basic structural and functional studies used for the diagnosis of pain related problems. Attention will also be given to the limitations of such studies and the importance of establishing clinical relevance to their findings. Factors that adversely affect clinical management potentially resulting in failed treatment will be discussed as well as best practices when utilizing such studies to help enhance clinical outcomes for treatment.

Designer drugs are structurally related to illegal psychoactive drugs and include cathinones (bath salts and flakka), synthetic cannabinoids (K2), piperazines (Molly), salvia, kratom, and desomorphine (krokodil). Often designer drugs are readily available on the Internet or in head shops and skirt regulation through the development of novel analogs and labeling the products "not for human consumption." These novel psychoactive substances are consumed typically by younger males via various routes and modes for their desirable effects; however, undesirable and even life-threatening reactions or death may occur. Additionally, designer drugs are often coingested with other psychoactive substances and may be metabolized through cytochrome P450 pathways leading to drug-drug interactions furthering the potential for harm. Management is normally with supportive measures and symptomatic care. Unfortunately, most of these agents are challenging to detect as they are not readily identified by immunoassay urine drug testing, though some may lead to false positives. More advanced testing with liquid or gas chromatography/mass spectroscopy is able to detect designer drugs but is limited due to its availability, cost, delay in results, and the ever-changing designer drug structures.

There is a significant amount of media, political, and public attention paid to the opioid crisis/opioid epidemic in the United States today. With the seemingly ever-increasing number of opioid-related overdoses and fatalities, there has been a feverish push by stakeholders to diminish the amount of opioids prescribed in order to help stem these worrisome trends. Unfortunately, there may be a lack of focus regarding the true definition and characterization of the opioid epidemic. There may also be a rush to judgment about the role of appropriately prescribed opioid analgesics in the addiction crisis we face today as well. This presentation will discuss the roles and statistics of both prescription and illicit opioids (namely heroin and fentanyl) in today's "opioid overdose epidemic" with the intention of clarifying important differences and similarities between these competing epidemics including concerns and clinical considerations specific to each of them. Additionally, this program will examine and identify how these medications and drugs share potentially tragic adverse effect profiles in many cases. However, it is important for clinicians to make sure that appropriate chronic pain patients that may be candidates for opioid analgesic therapy aren't penalized, and still get the treatment that they deserve.

The CDC guidelines have caused controversy and spurred heated discussion. Produced with a paucity of evidence based medicine, they were never evaluated and iterated in the manner of more appropriate guidelines. In this course, we will examine the guidelines and their effect on practitioners--primary care physicians, pain specialists, etc--and chronic pain noncancer patients as well as some chronic cancer patients. Many functioning patients have had their opioid dosages diminished, either in concert with their physician or forcibly, without any say in the matter. This, along with a marked reduction in the amount of legal opioid medications that can be produced, has led to significant unintended consequences: practitioners are leaving the field; some refuse to even prescribe any opioids, mostly due to fear of overregulation; once functional patients are being abandoned by the medical field; patients are searching for something to return them to functionality, which can lead to overdose and death, particularly from heroin and illicit fentanyl. Indeed, the opioid crisis has now become the heroin and fentanyl crisis. During this presentation, solutions, and the changes necessary to bring them about, will be discussed.

Nonopioid analgesics are oftentimes considered first-line therapy for most chronic pain syndromes. A strong understanding of these agents' mechanism of action, pharmacokinetics, and toxicity profiles is paramount for today's pain practitioner. This course will provide an in-depth look at each of the agents within these drug classes, their potential role in pain management, and available data supporting their use. Additionally, clinically relevant monitoring pearls will be discussed.

The most contentious, poorly understood analgesics today are methadone and buprenorphine. This fast paced workshop will equip practitioners with immediately implementable practical tips regarding when and how to use these analgesics, including dosage formulations, routes of delivery, appropriate use in therapy, drug interactions, dosage titration (both up and down), opioid conversion calculations, and more. All discussions will be aimed at enhancing clinical, economic, and humanistic outcomes on the individual patient and health system level.

Program Overview: Pain is a significant public health problem, affecting more than 100 million adults in the US and causing significant reductions in patients' quality of life. The use of narcotic medications for pain management has increased dramatically in the US over the past two decades. However, pain patients are often undertreated due to a variety of physician- and patient-related concerns and barriers.

In addition, despite the pain-relieving properties of opioid medications, the potential for abuse remains a concern. In response to this apprehension about opioid misuse, overdose, abuse, and addiction, the Food and Drug Administration (FDA) developed the Risk Evaluation and Mitigation Strategy (REMS) to ensure that the benefits outweigh the risks for long-acting and extended-release opioid analgesics.

The activity, Extended-Release and Long-Acting Opioid Analgesics: Risk Evaluation and Mitigation Strategy (REMS), incorporates the REMS blueprint into education that is designed to induce changes in physician knowledge, competence, and performance that will translate into improved quality of patient care and reduced pain for patients.

Target Audience: This education is intended for primary care providers and other clinicians involved in pain management, and is designed to help them recognize and balance optimal pain reduction to improve function and productivity with minimization of adverse events (e.g. abuse, addiction, and risk of workplace accidents). Additional challenges to optimal pain management include keeping up to date with the increasing volume of information on pain management, implementing changes recommended by evolving guidelines, and recognizing changes to practice needed to combat the growing rate of opioid abuse.

Jointly provided by Global Education Group and Rockpointe

This educational activity is supported by an independent educational grant from the Extended-Release/Long-Acting Opioid Analgesic REMS Program Companies. Please see http://ce.er-laopioidrems.com/IwgCEUI/rems/pdf/List_of_RPC_Companies.pdf for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Extended-Release/Long-Acting Opioid Analgesics REMS education requirements issued by the US Food & Drug Administration.